Visualise a future…

Sight is the sense most people would fear losing the most, but
as a society we spend only 1.6 per cent of the total NHS budget
(about £1.2bn) to prevent, detect and treat eye disease.
Typically, eye health services are overloaded and
under-resourced.

Government also spends relatively little to support independent
living for people with sight loss, in total about £1.1bn. Key
services such as low vision, rehabilitation, social support,
community equipment, disability benefits and accessible transport
are generally under-funded and under-developed.

In the absence of adequate statutory services for blind and
partially sighted people, it is left to family and friends to help
out – this costs some £1.5bn.(1) This informal support covers
activities such as help in the home, shopping, reading mail and
transport.

Another £1bn represents productivity loss to the economy,
due to the much higher unemployment rate experienced by blind and
partially sighted people. Three out of four people with visual
impairment are not in paid employment, a figure which has not
changed significantly over the past 10 years. This also explains
the poverty and social exclusion of many blind and partially
sighted people of working age.(2)

Add these figures together and it gives us an estimate of
£4.9bn annually for the cost of blindness. If central and
local government provided quality services across the whole of the
UK public expenditure would inevitably rise. However, targeted
expenditure on four areas – prevention, raising awareness, early
detection and treatment – could help to reduce the overall cost to
society of sight loss, as well as saving sight.

It is crucial that government invests in awareness campaigns to
alert the public to health issues such as the proven link between
smoking and sight loss, the importance of regular eye tests, in
providing proven, sight-saving treatments.

As well as this investment, which will in time pay off by
reducing the incidence of sight problems, more expenditure is also
required on the key areas of low vision services, community care
and equipment, disability benefits, transport and employment
support. These areas would assist blind and partially sighted
people to be more independent and help some contribute to the
economy through work.

This investment is needed now. Sight problems are experienced
predominantly by older people. By 2020, it is estimated that the
number of people over 60 in the UK will increase by 24 per cent.
The increase in the over-80 age group is sharper still. The
incidence of visual impairment is projected to rise by about 35 per
cent by 2020, largely accounted for by the increase in numbers of
older people. This will mean a sharp rise in demand for services to
prevent and treat eye disease, as well as services to support
independent living.

In the cases of primary and secondary eye care, services need to
be developed and modernised in a way that makes the most efficient
use of resources and staff skills.

Agencies, professionals and voluntary groups are aware of the
fragmented nature of services available to people with sight
problems. The gaps between medical intervention, low vision
assessment and social care input vary greatly across the UK. And
lack of timely intervention is stated as a cause of poor
rehabilitative outcomes.

The Royal National Institute of the Blind attempted to start
addressing these problems in May 2002 in partnership with Camden
primary care trust, Islington primary care trust and their local
authorities. They opened a state-of-the-art low vision service
where rehabilitation workers and optometrists work together as one
team. This provides greater value as the service is person-centred
and allows a care plan to be designed that allows the user to make
the best use of their residual sight and gives them a deeper
understanding of their visual problem.

It also makes it possible to apply this information to reduce
the risk of falls by giving advice regarding restricted visual
fields and the use of lighting, for example. Reducing the incidence
of falls cuts costs both in secondary care and on the patient’s
return to the community.

Further benefits are that patients are less anxious about
deterioration of vision, safety at home and about coping with
everyday life. This increases their ability to maintain an
independent lifestyle for longer than would be likely otherwise,
again reducing costs. In addition, the likelihood of depression, so
common with sight loss, is reduced.

The RNIB, with primary care trusts, social services and local
voluntary societies, are setting up two new pilot low vision
services, one in Barking, Dagenham and Havering, and the other in
Gateshead. These will open in the autumn. These are part of a wider
programme of pilot sites that are being funded by the Department of
Health for two years, with commitment from the PCTs to continue
funding after this.

This initiative came about following the publication of the
first report of the National Eye Care Steering Group set up by the
DoH in 2002 to review the issues around the fragmented nature of
services.

The pilot sites aim to provide integrated services and ensure
easy access for all people in relation to a number of sight
problems or eye conditions, including glaucoma, age-related macular
degeneration, cataracts and low vision. Lessons learned from the
pilots will be widely shared and implemented by all primary care
trusts.(3)

As with the RNIB service in London, these low vision services
will provide local delivery and users will also be able to take
advantage of a specialist resource centre and social facilities
enhancing the “one-stop shop” nature of the service. They will also
provide a domiciliary service as well as sessions for people with
special needs. The needs of people from ethnic minority backgrounds
will be taken into account to ensure equal access to the
service.

Low vision particularly affects the older population. Seamless,
integrated provision of both rehabilitation and low vision services
will be crucial in meeting client needs and of even greater value
as the number of older people in the population increases.

Stephen Winyard is head of public policy with the Royal
National Institute of the Blind. He is responsible for its
lobbying, campaigning and policy activities. He recently completed
a visiting fellowship at Nuffield College Oxford, researching the
cost of blindness in the UK.

Abstract

Demographic change and improvements in health care are leading
to an increasingly elderly population and longer life expectancy.
This will mean a dramatic increase in demand for services for older
people with sight problems by 2020. Investing now in prevention,
raising awareness, early detection and treatment as well as key
services is the only long-term, sustainable strategy that could
both reduce spending and save sight.